This paper features an innovative program that combines “Integrated Play Groups” and “Sensory Integration Therapy” to address the unique social, play and sensory needs of children with autism spectrum disorders (Wolfberg, 1999; 2003; Berry & Fuge, 2004). Drawing from current research and practice, this combined program builds on our knowledge of play, peer relations and sensory processing as related to children on the autism spectrum. Through a carefully tailored system of support, emphasis is placed on maximizing children’s developmental potential as well as intrinsic desire to play, socialize and form relationships with peers and siblings. An equally important focus is on teaching the peer group to be more accepting, responsive and inclusive of children who relate and play I different ways.

Features of the Integrated Play Groups (IPG) Model
IPGs are designed to support children of diverse ages and abilities with ASD (novice players) in mutually enjoyed play experiences with typical peers and siblings 9expert players). Guided by theory, research and evidence practices, this multi-dimensional model incorporates parameters known to affect social interaction, communication, play and imagination in children with ASD (for an overview of theory and methods see Wolfberg, 1999; 2003; Wolfberg & Tuchel, submitted for publication; for an overview of efficacy research see Wolfberg & Schuler, in press). The model specifically infuses the notion of “guided participation” described as the process through which children develop while actively participating in culturally valued activity with the guidance, support and challenge of companions who vary in skill and status (Vygotsky, 1966/33; Rogoff, 1990).

IPGs are customized for children (ages 3 to 11 years) as a part of an educational or therapeutic program. Small groups of children regularly play together under the guidance of an adult facilitator (play guide). Each group comprises three to five children with a higher ratio of expert players (typically developing peers/siblings) to novice players (children with ASD). Groups may vary with respect to children’s gender, ages, developmental status and play interaction styles.

IPGs take place in natural play environments within school, home, therapy or community settings. Play areas are designed based on a consideration of multiple factors including physical size, density, organization and thematic arrangements of materials. Play materials include a wide range of highly motivating manipulative/sensory, functional/constructive and sociodramatic props with high potential for interactive and imaginative play. Play materials vary in degree of structure and complexity to accommodate children’s diverse interests, learning styles and developmental levels. Play sessions are structured by establishing consistent schedules, routines and rituals and incorporating visual supports that foster familiarity, predictability and a cohesive group identity.

The assessment process hinges on careful and detailed observations of children at play. This provides a basis for setting realistic goals, guiding intervention strategies, and documenting children’s progress. An observation framework and corresponding assessment tools have been developed for use with this model (Wolfberg, 2003).

Guided by assessments, the intervention, guided participation, translates into a carefully tailored system of support that is responsive to each child’s underlying difference and unique developmental profile. The idea is to enhance opportunities that allow novice and expert players to initiate and incorporate desired activity into socially coordinated play while challenging novice players to practice new and increasingly complex forms of play. The adult methodically guides novice and expert players to engage in mutually enjoyed play activities that encourage social interaction, communication, play and imagination-such as pretending, constructing, art, music, movement and interactive game. Gradually the adult weans herself out as the children learn t mediate their own play activities. Play guides apply the following key set of practices:

• Monitoring play initiations, focuses on uncovering novice players’ meaningful attempts to socialize and play by recognizing, interpreting and responding to the subtle and idiosyncratic ways in which they express intentions to play in the company of peers.
• Scaffolding play involves building on the child’s play initiations by systematically adjusting assistance to match or slightly exceed the level at which the child is independently able to engage in play with peers within the child’s “zone of proximal development.”
• Social-communication guidance focuses on supporting novice and expert players in using verbal and nonverbal social-communication cues to elicit each other’s attention and sustain joint engagement in mutually enjoyed play activities.
• Play guidance encompasses a set of strategies that support novice players in peer play experiences that are slightly beyond the child’s capacity while full immersed in the whole play experience at his or her present level, even if participation is minimal.

Features of Sensory Integration (SI) Therapy
SI therapy centers on enhancing children’s organization and processing of sensory information received through the senses. Occupational and physical therapists play a key role in facilitating the therapeutic process by carefully selecting and guiding children in intrinsically motivating, child-centered sensory motor play activities.

SI assists children in processing and responding to information so that they can maintain an optimal arousal state for functional tasks. Our genes give us the baseline capacity for sensory integration. All children are born with this capacity and must develop sensory integration by interacting with the environment, responding to the challenges of childhood and making adaptive responses (Ayres, 1979).

Many children with autistic spectrum disorders and others with attentional difficulties are unable to process and organize sensory information effectively. Sensory integration disorders are commonly classified and modulation, discrimination or regulatory disorders. Underreaction, overreaction, or fluctuation between the two extremes in response to sensory input is the outward manifestation of a sensory integration disorder (Bundy, 1991).

By using a SI treatment approach, therapists can determine how children are processing information and provide them with the sensory input that offers the “just right challenge” for organizing and regulating the sensory system. Therapy, based on principles of SI provides children with activities that incorporate opportunities for sensory intake. The treatment approach utilizes a variety of methods of stimulation (vestibular, tactile, proprioceptive, visual, auditory, gustatory and olfactory) and provides building blocks for functional skills. These skills are not taught, but are allowed to emerge spontaneously as foundations develop.

Many children with autism are thought to learn best when the information is presented visually. However, in treatment sessions it is sometimes necessary to bombard the system with multi-sensory approach (olfactory, tactile, proprioception and vestibular) prior to a learning activity. This SI treatment allows the child to get the input they are seeking (sometimes in bizarre ways) in a more appropriate manner. Thus, their needs are met so that they are able to focus attention on the task at hand (Berry & Fuge, 2004).

Bundy (1991) describes the role of play within a SI framework as a powerful tool for treatment. Therapy using the principles of SI may be very helpful in facilitating the development of play if it is carefully planned and conducted. Likewise, play as a part of a well-orchestrated treatment play can result in improvements in sensory integration.

The most effective, enjoyable and productive environment for working with children is one in which the atmosphere is relaxed, mutually supportive and playful. Interventions are designed to be intrinsically motivating and child-centered in order to capitalize on the child’s attention and motivation as well as innate drive to move, explore, and learn through pleasurable experiences. In therapy, activities incorporate play to achieve goals and objectives such as postural responses, concept development and fine motor development. Activities selected for preschool and order children revolve around spontaneous interests. Thus, appropriate space and equipment are critical to success.

Play provides children opportunities for exploration, interactions and challenges that have a positive influence on the nervous system (Schaaf, 1997). SI therapy involving play-based activity is distinguished by several important characteristics:
•Activities are engaging and integrated
•Activities acknowledge the importance of play
•Activities emphasize functional skill development and generalization of skills
•Activities are carried out in a stimulating and responsive atmosphere
•Therapists follow the child’s lead keeping in mind that play belongs to the children, not the adults
•Therapists stick to themes the children are exploring
•Therapists expand the play only when needed
•Therapists allow the children time to master skills (Coling & Garret, 1995)

By including play in a SI therapy session and by using a playful approach, therapists acknowledge and pursue joy in the practice of authentic therapy (Royeen, 1997). Thus, play becomes a balanced partnership with Sensory Integration and Integrated Play Groups as the supporting foundation.

Research on Efficacy of SI-IPG Interventions
Several recent studies have provided preliminary data to support the efficacy of the SI-IPG intervention. A chart and video review of 13 children with ASD who were currently receiving the SI-IPG intervention at Developmental Pathways for Kids found significant improvements in the social dimension of play (p=. 007), the rate of social initiation-responsiveness (p=. 008), quality of social interaction-responsiveness (p=. 014), fine motor skills (p=. 039) and gross motor skills (p=. 026). Parents of the children also completed an open-ended parent perception questionnaire. Changes in social and play behaviors observed by parents were reflected in ix themes: sibling/peer friendships and relationships, increase in peer interaction, changes in overall well-being, diversity in play, and changes in skills and behaviors (Schaefer & Atwood, 2003).

A retrospective chart review of seven children who had completed the SI-IPG intervention evaluated changes in social and symbolic dimensions of play. The two children in the study with autism experienced substantial growth in social dimensions of play (6 and 7 point improvement on a 10-point scale), but made minimal or no changes in symbolic dimensions of play. The other five children, with diagnoses of sensory processing disorder, Asperger’s syndrome, and developmental delay, made minimal or no changes in either area (Antipolo & Dichoso, 2003).

Case studies of tow children with ASD who received 10 weeks of SI-IPG intervention in the San Jose State pediatric occupational therapy clinic found increases in duration of play engagement, self-regulation, symbolic and social dimensions of play. Parents also noticed an increased interest in spontaneous play with siblings at home (Mahnken, Baiardo, Naes, Pechter, & Ricchardson, 2004). The results of these studies, while limited in scope and size, support further investigation into the outcomes of this intervention, particularly how well children can generalize play and social skills into home and school environments.

Conclusion
Combining SI and IPG allows therapists to carefully craft way s in which to engage children in play experiences that are not only developmentally appropriate and therapeutic in nature, but also reflect the natural play experiences of typically developing children. By blending practices, children are afforded opportunities to perform and master a host of necessary skills to acquire social competence, effective communication, adaptive behavior and flexible imagination. With explicit structure and support, they learn how to attend, observe, follow, imitate, share space and materials, coordinate actions and carry out pretend play scripts with peers. Throughout this process, play is recognized not only as a vehicle to learning and development, but as a most meaningful part of childhood that enables children to simply have fun and make friends.

References
Refer to the 2004 National Conference of the Autism Society of America Conference Proceedings.